Chiropractic Treatment and Rheumatoid Arthritis

What is Rheumatoid arthritis?

Rheumatoid arthritis (RA) is a specific type of arthritis that is
chronic, progressive and often debilitating, characterised by the
symmetrical joint involvement and the age at which it begins.

It differs
from the more common osteoarthritis (OA) often known as wear and tear, spondylosis, degenerative joint disease (DJD) or rheumatism.

It can also affect other parts of the body such as the heart, lungs,
small blood vessels, the nervous system and eyes.

When this occurs, it
is referred to as rheumatic disease.
Any type of arthritis involves inflammation which can cause redness,
swelling, stiffness, pain, loss of joint function and eventually joint
deformity.

Nobody knows what causes or triggers RA, but it has long been
believed that infectious agents such as bacteria, viruses and fungi are
involved in starting the inflammatory chain of events, although none
have been proven as yet.

Some scientists believe that certain
environmental factors can trigger the inflammation to start, and that
there is a hereditary link to RA with genetic make-up influencing who is
susceptible to it.

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Who is affected by Rheumatoid arthritis?

RA affects two to three times more women than men and typically occurs
between the ages of 25 and 50 years of age, although the onset can vary
to affect children as young as six months old as with juvenile rheumatoid arthritis (Still’s disease)? also known as juvenile idiopathic arthritis (JIA).

The joints affected by rheumatoid arthritis differ to those
affected by osteoarthritis due to the nature of the disease. OA affects
the weight bearing joints, which become more prone to erosion through
wear and tear. The affected joint distribution is usually
non-symmetrical and can affect the whole spine.

With RA, it is the synovial joints (specific type of joint) that are
affected. The distribution tends to be symmetrical - with the most
common joints affected being the smaller joints of the hands and feet,
although it can affect any synovial joint. RA for example will tend to
affect the smaller joints of the hands and wrists away from the
fingernails, where as OA will favour the joints closest to the
fingernails.

To date, no-one really knows why some joints are affected over
others with RA. In the past, some theories have included an increased
blood supply being responsible for targeting the specific joints,
although to date, these have not been proven.

How a normal joint works

In a normal joint, the bone surfaces are lined with cartilage, which
acts to reduce friction and helps absorb the stresses that are placed on
the joint in everyday situations.

Surrounding the joint is a very thin
membrane (called the synovial membrane or synovium) that produces
synovial fluid, and acts like a sac.

This fluid is important in
providing the nutrients needed to feed the cartilage to make sure it is
healthy and provides as much lubrication as possible within the joint.

Encapsulating the joint and synovium is the joint capsule – a tough
coating which keeps everything together - to which ligaments and tendons
surround, providing stability and movement to the joint.

Damage to any
of these structures can result in pain and swelling around the joint
with a potential loss of function depending on the structure that has
been injured.

In Osteoarthritis, as a result of repeated stresses and shock absorbing, the
joint space starts to narrow and the cartilage within the joint starts
to wear away, becoming damaged.

It becomes thinner and no longer
provides as much lubrication as before. The joint surfaces therefore
start to rub, causing irritation and pain which in turn causes
inflammation and swelling.

The bone surfaces react to this change by
laying down more bone often in the form of spurs at the end of the bones
themselves. The joint becomes deformed as a result causing further pain
and stiffness, and loss of normal movement.

These changes can be seen on X-Ray as a narrowing of the normal
joint space, changes in the bone density (areas of increases whiteness)
directly at the joint and bony spurs (osteophytes) present on the outer
margins of the affected joints.

In Rheumatoid Arthritis, usually an infection or incident will trigger the bodys’
immune system to attack its own tissues and start the inflammatory
process.

The white blood cells infiltrate the synovium surrounding the
joints causing them to become inflamed. This causes an excess production
of fluid within the joint itself and thickening of the synovial
membrane (pannus formation).

Pannus progresses to spread throughout the
whole joint and starts to erode away the cartilage covering the ends of
bone, and eventually the bone surfaces which ultimately results in the
deformation of the joint.

The changes can be seen on X-ray as the bone surfaces and margins are eaten away.

What are the symptoms of Rheumatoid arthritis?

The symptoms of RA can vary from person to person. When the disease
is active, the tissues are inflamed. When the disease is in remission,
the inflammation has eased and the symptoms disappear with patients
generally feeling well.

Remissions can occur spontaneously or with
treatment and can vary in length between weeks and years in duration.
When the disease becomes active again the symptoms return.

The first symptoms of RA can start as pain, swelling and
stiffness in one or more of the same joints in both sides of your body
(symmetrical distribution). They can start suddenly (acute onset) or
more commonly, over a longer period of time (insidious onset).

The
morning joint stiffness lasts considerably longer than 30 minutes and is
often accompanied with poor sleep due to waking up in the middle of the
night from the joint pain and stiffness.

Patients will often experience
fatigue, weight loss and generally feel unwell or have flu-like
symptoms.

Extra-articular features of Rheumatoid arthritis

Other parts of the body can also be affected, although this doesn’t
happen with everyone. The inflammation of RA can cause swelling under
the skin in the form of rheumatic nodules - firm, non-tender nodules
under the skin present in approximately 25% of patients with RA.

These
typically occur at bony areas where there is frequent pressure such as
the elbows, but can also occur elsewhere in the body including the
internal organs. Even though these do not cause any symptoms, they can
occasionally become infected.

RA patients can also develop inflammation of the membranes
surrounding the internal organs such as the heart causing pericarditis,
nodules and ischaemic heart disease.

In some cases the lung tissue
becomes inflamed (pleuritis), causing again nodules and fibrosis.
Inflammation of the tear glands in the eyes and salivary glands in the
mouth is often referred to as Sjögren’s syndrome, and will result in dry
eyes and mouth.

Rarely, inflammation can affect the blood vessels
(vasculitis) causing problems with the skin in the form of ulcers and
the nerves. It is usually visible as tiny black areas around the nail
beds or as leg ulcers.

Diagnosis of Rheumatoid arthritis

Your GP and usually a consultant rheumatologist (joint specialist)
are required to confirm the diagnosis and will base it on whether a
certain number of criteria have been filled. These may be less obvious
during the early stages of the disease, but can be confirmed with blood
test results.

A specific marker within the blood (rheumatoid factor or RF) is
often present in RA and a selection of other inflammatory conditions
such as Sjorgen’s syndrome, dermatomyositis, scleroderma, systemic lupus
erythematosus (SLE). However, if RF is not present it does not
necessarily mean that you do not have RA, and likewise, if you do have
RF it does not necessarily mean that you have RA. There are two
different types of RA – sero-positive RA when RF is present in the
blood, and sero-negative RA when RF is not present in the blood.
However, the type of RA does not influence the treatment in any way – it
is used as a diagnostic aid for the diagnosing physician.

Below are the criteria that must be present for at least six weeks for a diagnosis of RA to be made:

Stiffness in and around the joints lasting for at least 1 hour in the morning

Swelling in the area surrounding the joints in three or more joint areas at any one time

Swelling of the first finger (proximal interphalangeal), hand or wrist joints

Symmetrical swelling.

Once diagnosed with RA, the physician needs to determine at
what stage of the disease you are in to come up with the most effective
treatment plan and rehabilitation program. This is usually defined
through the presence of rheumatic nodules, rheumatoid factor and x-ray
changes.

Treatment and management of Rheumatoid arthritis

Due to the nature of the condition, the focus of the treatment is to
suppress the joint damaging process. This is usually achieved through
medication to control the inflammation and disease progression and is
usually administered in the form of DMARDs, steroids and biologic
agents. In advanced cases where medication is not sufficiently
controlling the joint damage, surgery might be required to deal with
structural changes.

An early diagnosis is important to minimise the amount of joint
damage and complications that can occur with RA and improve the quality
of life.

Once under control, there are several ways to ease the symptoms. These include:

education about the condition and support to patients with RA and their families,

pain-killers and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen,

immuno-supressants

joint injections and

pain management clinics.

Can chiropractic help?

Chiropractic treatment is concerned with the diagnosis, treatment and
prevention of disorders of the neuro-musculoskeletal system. This means
we focus mainly on the nervous system, the muscles and joints of the
body and aim to make them work as well as they possibly can do.

Having taken a full and thorough history and completed a full
examination, your chiropractor will discuss the treatment options with
you and how best to optimise the care given in between treatments.

This
may be in the form of mobility, strengthening and supporting exercises,
icing and heat advice, and advice in a choice of supporting aids as part
of the multi-professional care team needed for patients with RA.

The Chiropractic management itself will focus on easing the
stiffness in joints built up from immobility and lack of use from pain,
and relaxing tight muscles aimed at maximising joint function and
mobility.

The techniques used will vary depending on your individual
circumstances and presentation as not all types of treatment are
appropriate for everyone. The use of a Low Level LAser Theraapy or cold laser has been shown to be effective in controlling inflammation and improve healing.